神经重症患者术后多模态监测技术的应用研究

Study of multimodal monitoring in neurocritical care patients

目的探讨多模态监测技术在神经重症患者监测治疗中的意义.方法选取2019年3月至2020年1月福建省立医院重症医学科收治的104例神经重症患者,按完全随机化方法将患者分为两组,每组52例.常规监测治疗组术后心电监测患者心率、血压、呼吸,观察意识、瞳孔变化,给予常规脱水降颅压、维持合适脑灌注压(CPP)、平衡出入量、保持气道通畅等治疗;多模态监测治疗组患者进行有创颅内压(ICP)监测、颅脑超声结构性评估、超声视神经鞘直径(ONSD)测量、经颅彩色多普勒超声(TCCD)、颈内静脉血氧饱和度监测、近红外光谱(NIRS)测量、无创脑血氧饱和度监测及量化脑电图监测,根据监测结果给予相应控制ICP、改善脑代谢治疗.比较两组重症监护病房(ICU)住院时间、神经系统并发症(继发性脑梗死、脑出血、高颅内压等)发生率、预后不良〔发病后6个月格拉斯哥预后评分(GOS)1~3分〕发生率.用Spearman秩相关分析有创ICP值与TCCD计算ICP值的相关性;采用受试者工作特征曲线(ROC)分析有创ICP、大脑中动脉搏动指数(PIMCA)对不良预后的预测价值.结果多模态监测治疗组患者ICU住院时间明显短于常规监测治疗组(d:6.27±3.81比9.61±5.09,P<0.01),神经系统并发症发生率明显低于常规监测治疗组(9.62%比25.00%,P<0.05).多模态监测治疗组预后良好37例、预后不良15例,常规监测治疗组分别为27例、25例,多模态监测治疗组预后不良发生率低于常规监测治疗组(28.85%比48.08%,P<0.05).在多模态监测组中,预后良好患者有创ICP、PIMCA显著低于预后不良患者〔有创ICP(mmHg,1 mmHg=0.133 kPa):16(12,17)比22(20,24),PIMCA:0.90±0.33比1.39±0.58,均P<0.01〕.而预后良好者与预后不良者大脑中动脉阻抗指数(RIMCA)差异无统计学意义(0.63±0.12比0.66±0.15,P>0.05);相关性分析显示,有创ICP与TCCD计算ICP值呈正相关性(r=0.767,P<0.001).ROC曲线分析显示,有创ICP对不良预后预测的ROC曲线下面积(AUC)为0.906,最佳截断值为有创ICP≥18 mmHg时,敏感度为86.49%,特异度为86.67%;PIMCA对不良预后预测的AUC为0.759,最佳截断值为PIMCA≥1.12时,敏感度为81.08%,特异度为60.00%.有创ICP的AUC大于PIMCA(Z=2.279,P=0.023).结论综合分析神经重症多模态监测指标指导临床治疗,可减少患者住院天数,降低神经重症并发症及致残率;有创ICP可预测神经重症患者预后不良.

Objective To explore the significance of multimodal monitoring in the monitoring and treatment of neurocritical care patients.Methods 104 neurocritical care patients admitted to the department of Critical Care Medicine of Fujian Provincial Hospital from March 2019 to January 2020 were enrolled.Patients were randomly assigned into two groups,with 52 in each group.In the routine monitoring treatment group,heart rate,blood pressure,respiratory rate and the changes in consciousness and pupils were monitored after operation.The patients were treated with routine medicine to reduce intracranial pressure(ICP),maintain proper cerebral perfusion pressure(CPP),balance fluid intake and output,and maintain the airway clear.Patients in the multimodal monitoring treatment group were treated with invasive ICP monitoring,ultrasound to assess brain structure,ultrasound to measure optic nerve sheath diameter(ONSD),transcranial color doppler(TCCD),internal jugular venous blood oxygen saturation monitoring,near-infrared spectroscopy(NIRS),non-invasive cerebral blood oxygen saturation monitoring and quantitative electroencephalogram monitoring.According to the monitoring results,the patients were given targeted treatment with the goal of controlling ICP and improving brain metabolism.The length of intensive care unit(ICU)stay,the incidences of neurological complications(secondary cerebral infarction,cerebral hemorrhage,high intracranial pressure,etc.),and the incidences of poor prognosis[6 months after the onset of Glasgow outcome score(GOS)1 to 3]were compared between the two groups.Spearman rank correlation analysis of the correlation between invasive ICP and the ICP value which was calculated by TCCD.The receiver operating characteristic(ROC)curve of invasive ICP and pulsatility index of middle cerebral artery(PIMCA)were used to predict poor prognosis.Results The length of ICU stay in the multimodal monitoring treatment group was significantly shorter than that of the routine monitoring treatment group(days:6.27±3.81 vs.9.61±5.09,P<0.01),and the incidence of neurological complications was significantly lower than that in the routine monitoring treatment group(9.62%vs.25.00%,P<0.05).In the multimodal monitoring treatment group,37 cases had a good prognosis and 15 cases had a poor prognosis,while the routine monitoring treatment group had a good prognosis in 27 cases and a poor prognosis in 25 cases.The incidence of poor prognosis in the multimodal monitoring treatment group was lower than that of the routine monitoring treatment group(28.85%vs.48.08%,P<0.05).In the multimodal monitoring treatment group,the invasive ICP and PIMCA of patients with good prognosis were significantly lower than those of patients with poor prognosis[invasive ICP(mmHg,1 mmHg=0.133 kPa):16(12,17)vs.22(20,24),PIMCA:0.90±0.33 vs.1.39±0.58,both P<0.01].There was no significant difference in resistance index of the middle cerebral artery(RIMCA)between the good prognosis group and the poor prognosis group(0.63±0.12 vs.0.66±0.15,P>0.05).There was a positive correlation between the invasive ICP and the ICP value which was calculated by TCCD(r=0.767,P<0.001).ROC curve analysis showed that the area under ROC curve(AUC)of invasive ICP for poor prognosis prediction was 0.906,the best cut-off value was≥18 mmHg,the sensitivity was 86.49%,and the specificity was 86.67%.The AUC of PIMCA for poor prognosis prediction was 0.759,the best cut-off value was≥1.12,the sensitivity was 81.08%,and the specificity was 60.00%.The AUC of invasive ICP was greater than PIMCA(Z=2.279,P=0.023).Conclusion Comprehensive analysis of multimodal monitoring indicators for neurocritical care patients to guide clinical treatment can reduce the length of hospital stay,and reduce the risk of neurosurgery complications and disability;invasive ICP can predict poor prognosis of neurocritical care patients.